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Liu X, Tao Y, Yang B, Pang T, Yu L, Li W, Feng S, Liu R, Li J, Liu Z, Qiu J. A novel X-Ray and γ-Ray combination strategy for potential dose escalation in patients with locally advanced pancreatic cancer. Med Phys 2023; 50:1855-1864. [PMID: 36458937 DOI: 10.1002/mp.16142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Treatment of locally advanced pancreatic cancer (LAPC) has long been calling for advances in technology of radiotherapy. Patients who received radiotherapy still had high risks of local recurrence, while suffering from gastrointestinal side effects. Based on the inherent characteristics of the x-ray and γ-Ray radiation techniques, here we proposed and investigated an unexplored radiation therapy. PURPOSE To investigate the potential clinical benefit of a novel x-ray and γ-Ray combination radiation technique in patients with LAPC. METHODS Retrospective intensity-modulated radiotherapy (IMRT) treatment plans of 10 LAPC patients were randomly selected to compare with dual-modality plans. The prescribed dose to PGTV was 60.2 Gy. The PGTV dose was further escalated in dual-modality plan while maintaining clinically tolerable dose to organs at risk (OARs). Dosimetric comparisons were made and analyzed for three treatment plans (tomotherapy, standard dual-modality plan, escalated dual-modality plan) to assess the ability to increase dose to target volume while minimizing dose in adjacent OARs. Finally, radiobiological models were utilized for comparison. RESULTS All strategies resulted in dosimetrically acceptable plans. Dual-modality plans were present with similar conformity index (CI) and significantly lower gradient index (GI) compared with tomotherapy (3.64 ± 0.37 vs. 4.14 ± 0.61, p = 0.002; 3.64 ± 0.42 vs. 4.14 ± 0.61, p = 0.003). Dmean of PGTV (65.46 ± 3.13 vs. 61.56 ± 1.00, p = 0.009; 77.98 ± 5.86 vs. 61.56 ± 1.00, p < 0.001) and PCTV (55.04 ± 2.14 vs. 53.93 ± 1.67, p = 0.016; 58.24 ± 3.24 vs. 53.93 ± 1.67, p = 0.001) were significantly higher, while Dmean of the stomach was reduced in both dual-modality plans (17.98 ± 10.23 vs. 19.34 ± 9.75, p = 0.024; 17.62 ± 9.92 vs. 19.34 ± 9.75, p = 0.040). The lower V30Gy in the liver (4.83 ± 5.87 vs. 6.23 ± 6.68, p = 0.015; 4.90 ± 5.93 vs. 6.23 ± 6.68, p = 0.016) and lower V45Gy of the small intestine (3.35 ± 3.30 vs. 4.06 ± 3.87, p = 0.052) were found in dual-modality plans. Meanwhile, radiobiological models demonstrated higher probability of tumor control (29.27% ± 9.61% vs. 18.34% ± 4.70%, p < 0.001; 44.67% ± 18.16% vs. 18.34% ± 4.70%, p = 0.001) and lower probability of small intestine complication (2.16% ± 2.30% vs. 1.25% ± 2.72%, p = 0.048) in favor of dual-modality strategy. CONCLUSIONS A novel dual-modality strategy of x-ray and γ-Ray combination radiation appears reliable for target dose escalation and normal tissue dose reduction. This strategy might be beneficial for local tumor control and the protection of normal organs in patients with LAPC.
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Affiliation(s)
- Xia Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinjie Tao
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingtian Pang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenbo Li
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siqi Feng
- Our United Corporation, Xi'an, Shaanxi, China
| | - Renqing Liu
- Our United Corporation, Xi'an, Shaanxi, China
| | - Jinsheng Li
- Our United Corporation, Xi'an, Shaanxi, China
| | - Zhikai Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lee JC, Shin DW, Park H, Kim J, Youn Y, Kim JH, Kim J, Hwang JH. Tolerability and safety of EUS-injected adenovirus-mediated double-suicide gene therapy with chemotherapy in locally advanced pancreatic cancer: a phase 1 trial. Gastrointest Endosc 2020; 92:1044-1052.e1. [PMID: 32084409 DOI: 10.1016/j.gie.2020.02.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Locally advanced pancreatic cancer (LAPC) is challenging. Here, we aimed to evaluate the tolerability and safety of Ad5-yCD/mutTK(SR39)rep-ADP (Ad5-DS), a replication-competent adenovirus-mediated double-suicide gene therapy in combination with gemcitabine in patients with LAPC. METHODS Patients with newly diagnosed LAPC were enrolled in this single-center, open-label, 3 + 3 dose-escalation phase 1 trial. Ad5-DS was injected into the pancreatic mass with EUS-guided fine needles combined with oral 5-fluorocytosine and valganciclovir, and a standard dose of intravenous gemcitabine. The doses of Ad5-DS in cohorts 1 to 3 were 1 × 1011, 3 × 1011, and 1 × 1012 viral particles (vp)/mL, respectively. Patients were observed for dose-limiting toxicity (DLT) for 8 weeks after Ad5-DS injection. Toxicity within 12 weeks, tumor response in 12 weeks, disease progression in 6.5 months, and detection of adenoviral DNA particles in 8 weeks were also assessed. RESULTS Among the 11 enrolled patients, 9 completed the evaluation period and 2 withdrew their consent. No DLT was reported; thus, the maximum tolerated dose was not reached. No additional toxicity was reported in 9 to 12 weeks. One patient showed a partial response and 8 showed stable disease at 12 weeks. Two patients showed disease progression at 6.5 months (median progression-free survival, 11.4 months). At 8 weeks, serum adenoviral DNA particles were detected in 4 patients (median, 55 days). CONCLUSION A combination of intratumoral Ad5-DS and gemcitabine is safe and well tolerated in patients with LAPC. This warrants further investigation in a larger clinical trial. (Clinical trial registration number: NCT02894944.).
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Affiliation(s)
- Jong-Chan Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea
| | - Dong Woo Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea
| | - Haeseong Park
- Division of Oncology, Alvin J Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jinkuk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea
| | - Yuna Youn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea
| | - Jae Hyeong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Bundang Hospital, Seongnam, Korea
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Meschini G, Kamp F, Hofmaier J, Reiner M, Sharp G, Paganetti H, Belka C, Wilkens JJ, Carlson DJ, Parodi K, Baroni G, Riboldi M. Modeling RBE-weighted dose variations in irregularly moving abdominal targets treated with carbon ion beams. Med Phys 2020; 47:2768-2778. [PMID: 32162332 DOI: 10.1002/mp.14135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/09/2020] [Accepted: 03/09/2020] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To model four-dimensional (4D) relative biological effectiveness (RBE)-weighted dose variations in abdominal lesions treated with scanned carbon ion beam in case of irregular breathing motion. METHODS The proposed method, referred to as bioWED method, combines the simulation of tumor motion in a patient- and beam-specific water equivalent depth (WED)-space with RBE modeling, aiming at the estimation of RBE-weighted dose changes due to respiratory motion. The method was validated on a phantom, simulating gated and free breathing dose delivery, and on a patient case, for which free breathing irradiation was assumed and both amplitude and baseline breathing irregularities were simulated through a respiratory motion model. We quantified (a) the effect of motion on the equivalent uniform dose (EUD) and the RBE-weighted dose-volume histograms (DVH), by comparing the planned dose distribution with "ground truth" 4D RBE-weighted doses computed using 4D computed tomography data, and (ii) the estimation error, by comparing the doses estimated with the bioWED method to "ground truth" 4D RBE-weighted doses. RESULTS In the phantom validation, the estimation error on the EUD was limited with respect to the motion effect and the median estimation error on relevant RBE-weighted DVH metrics remained within 5%. In the patient study, the estimation error as computed on the EUD was smaller than the corresponding motion effect, exhibiting the largest values in the baseline irregularity simulation. However, the median estimation error over all simulations was below 3.2% considering relevant DVH metrics. CONCLUSIONS In the evaluated cases, the bioWED method showed proper accuracy when compared to deformable image registration-based 4D dose calculation. Therefore, it can be seen as a tool to test treatment plan robustness against irregular breathing motion, although its accuracy decreases as a function of increasing soft tissue deformation and should be evaluated on a larger patient dataset.
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Affiliation(s)
- Giorgia Meschini
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Florian Kamp
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Gregory Sharp
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - David J Carlson
- Yale University, New Haven, CT, USA.,University of Pennsylvania, Philadelphia, PA, USA
| | - Katia Parodi
- Department of Experimental Physics -Medical Physics, Ludwig-Maximilians-Universität München (LMU Munich), Munich, Germany
| | - Guido Baroni
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy.,Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Marco Riboldi
- Department of Experimental Physics -Medical Physics, Ludwig-Maximilians-Universität München (LMU Munich), Munich, Germany
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Hrinivich WT, McNutt TR, Meyer JJ. Radiation treatment planning with embedded dose escalation. Radiat Oncol 2019; 14:145. [PMID: 31412952 PMCID: PMC6693221 DOI: 10.1186/s13014-019-1348-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/26/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Heterogeneous target doses are a common by-product from attempts to improve normal tissue sparing in radiosurgery treatment planning. These regions of escalated dose within the target may increase tumor control probability (TCP). Purposely embedding hot spots within tumors during optimization may also increase the TCP. This study discusses and compares five optimization approaches that not only eliminate homogeneity constraints, but also maximize heterogeneity and internal dose escalation. METHODS Co-planar volumetric modulated arc therapy (VMAT) plans were produced for virtual spherical targets with 2-8 cm diameters, minimum target dose objectives of 25 Gy, and objectives to minimize normal tissue dose. Five other sets of plans were produced with additional target dose objectives: 1) minimum dose-volume histogram (DVH) objective on 10% of the target 2) minimum dose objective on a sub-structure within the target, and 3-5) minimum generalized equivalent uniform dose (gEUD) objectives assuming three different volume-effect parameters. Plans were normalized to provide equivalent maximum OAR dose and were compared in terms of target D0.1 cc, ratio of V12.5 Gy to PTV volume (R50%), monitor units per 5 Gy fraction (MU), and mean multi-leaf collimator (MLC) segment size. All planning approaches were also applied to a clinical patient dataset and compared. RESULTS Mean ± standard deviation metrics achievable using the baseline and experimental approaches 1-5) included D0.1 cc: 27.7 ± 0.8, 64.6 ± 10.5, 56.5 ± 10.3, 48.9 ± 5.7, 44.8 ± 5.0, and 37.4 ± 4.5 Gy. R50%: 4.64 ± 3.27, 5.15 ± 2.32, 4.83 ± 2.64, 4.42 ± 1.83, 4.45 ± 1.88, and 4.21 ± 1.75. MU: 795 ± 27, 1988 ± 222, 1766 ± 259, 1612 ± 112, 1524 ± 90, and 1362 ± 146. MLC segment size: 4.7 ± 1.6, 2.3 ± 0.7, 2.6 ± 0.8, 2.7 ± 0.7, 2.7 ± 0.8, and 2.8 ± 0.8 cm. CONCLUSIONS The DVH-based approach provided the highest embedded doses for all target diameters and patient example with modest increases in R50%, achieved by decreasing MLC segment size while increasing MU. These results suggest that embedding doses > 220% of tumor margin dose is feasible, potentially improving TCP for solid tumors.
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Affiliation(s)
- William T Hrinivich
- Dept. of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N Broadway St. Weinberg Suite 1440, Baltimore, MD, 21231, USA.
| | - Todd R McNutt
- Dept. of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N Broadway St. Weinberg Suite 1440, Baltimore, MD, 21231, USA
| | - Jeffrey J Meyer
- Dept. of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, 401 N Broadway St. Weinberg Suite 1440, Baltimore, MD, 21231, USA
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5
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Meschini G, Seregni M, Molinelli S, Vai A, Phillips J, Sharp GC, Pella A, Valvo F, Ciocca M, Riboldi M, Paganetti H, Baroni G. Validation of a model for physical dose variations in irregularly moving targets treated with carbon ion beams. Med Phys 2019; 46:3663-3673. [PMID: 31206718 DOI: 10.1002/mp.13662] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 06/07/2019] [Accepted: 06/07/2019] [Indexed: 12/14/2022] Open
Abstract
PURPOSE In particle therapy, conventional treatment planning systems rely on an imaging representation of the irradiated region to compute the dose. For irregular breathing, when an imaging dataset describing the actual motion is not available, a different approach for dose estimation is needed. To this aim, we validate a method for the estimation of physical dose variations in gated carbon ion treatments, providing also a demonstration of the feasibility of physical dose metrics to assess the method performance. Finally, we describe a sample use case, in which this method is used to assess plan robustness with respect to undetected irregular tumor motion. METHODS The method entails the definition of a patient- and beam-specific water equivalent depth (WED) space, the simulation of motion as a translation equal to tumor displacement, and the reconstruction of the altered dose. We validated the approach using four-dimensional computed tomographies (4DCTs) and clinical plans in 12 patients, treated with respiratory gated carbon ion beams at the National Centre for Oncological Hadrontherapy (Pavia, Italy). Using the end-exhale CT and dose distribution as a reference, the physical dose delivered at the end-inhale tumor position was estimated and compared to the ground-truth dose recalculation on the end-inhale CT. Biologically effective and physical dose variations between the plan and the recalculation were compared as well. As a use case, we evaluated dose changes caused by simulated irregular tumor motion, that is, linear and nonlinear baseline shifts and/or amplitude variations with hysteresis. RESULTS The ratio between biologically effective and physical equivalent uniform dose (EUD) variations due to end-exhale to end-inhale motion was less than one for 96% of investigated structures. In the validation study, we found a median error corresponding to a 14% EUD overestimation for the tumor and 4% EUD underestimation for a subgroup of organs at risk, together with a high EUD variation due to motion [median 352% EUD variation between end-exhale and end-inhale doses in the planning tumor volume (PTV)]. Considering relevant dose-volume histogram (DVH) metrics, the median difference between estimated and ground truth doses was ≤ 4%. Gamma analysis between estimated and recalculated dose distributions resulted in a pass rate > 80% for 83% of the target volumes. For the two patients selected for the sample use case, a patient-specific assessment of the method performance was performed on the 4DCT and it was possible to relate EUD variations of both tumor and organs at risk to the simulated target motion. CONCLUSIONS The physical dose distribution was found to be more sensitive to motion with respect to the biologically effective one, suggesting the suitability of the physical dose metrics for the WED-space method validation. We showed that the method can compensate for intra-fractional tumor motion with proper accuracy in the selected patient group, although its use is recommended when limited deformations are expected. In conclusion, the WED-space method can provide simulations of dose alteration due to irregular breathing when imaging data are lacking, and, once integrated with relative biological effectiveness (RBE) modeling, it would be useful in evaluating the robustness of carbon ion treatment plans.
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Affiliation(s)
| | | | | | - Alessandro Vai
- Centro Nazionale Adroterapia Oncologica, Pavia, 27100, Italy
| | - Justin Phillips
- Alexian Brothers Medical Center, Elk Grove Village, IL, 60007, USA
| | | | - Andrea Pella
- Centro Nazionale Adroterapia Oncologica, Pavia, 27100, Italy
| | - Francesca Valvo
- Centro Nazionale Adroterapia Oncologica, Pavia, 27100, Italy
| | - Mario Ciocca
- Centro Nazionale Adroterapia Oncologica, Pavia, 27100, Italy
| | - Marco Riboldi
- Ludwig-Maximilians-Universität, Munich, 80539, Germany
| | | | - Guido Baroni
- Politecnico di Milano, Milan, 20133, Italy.,Centro Nazionale Adroterapia Oncologica, Pavia, 27100, Italy
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Anand A, Bues M, Gamez ME, Stefan C, Patel SH. Individual Field Simultaneous Optimization (IFSO) in spot scanning proton therapy of head and neck cancers. Med Dosim 2019; 44:375-378. [PMID: 30871863 DOI: 10.1016/j.meddos.2019.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/29/2019] [Accepted: 02/04/2019] [Indexed: 02/03/2023]
Abstract
In order to better spare organs at risk in the head and neck, the application of proton beam therapy is of great interest. In this study we report the clinical utilization of a novel and robust scanning proton beam therapy treatment planning method called Individual Field Simultaneous Optimization (IFSO) that incorporates the advantages of field patching technique integrated with simultaneous optimization of multiple fields. A treatment planning intercomparison between a conventional Intensity Modulated Proton Therapy Treatment Plan with single target volume vs a split target volume utilizing IFSO method demonstrates superiority of IFSO with regards to sparing of organs at risk and plan robustness.
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Affiliation(s)
- Aman Anand
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA.
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Corbin Stefan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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CyberKnife MLC-based treatment planning for abdominal and pelvic SBRT: Analysis of multiple dosimetric parameters, overall scoring index and clinical scoring. Phys Med 2018; 56:25-33. [DOI: 10.1016/j.ejmp.2018.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 12/31/2022] Open
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Arscott WT, Thompson RF, Yin L, Burgdorf B, Kirk M, Ben-Josef E. Stereotactic body proton therapy for liver tumors: Dosimetric advantages and their radiobiological and clinical implications. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 8:17-22. [PMID: 33458411 PMCID: PMC7807648 DOI: 10.1016/j.phro.2018.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 12/15/2022]
Abstract
Background and Purpose Photon Stereotactic Body Radiotherapy (SBRT) for primary and metastatic tumors of the liver is challenging for larger lesions. An in silico comparison of paired SBRT and Stereotactic Body Proton Therapy (SBPT) plans was performed to understand the potential advantages of SBPT as a function of tumor size and location. Methods and materials Theoretical tumor volumes with maximum diameter of 1–10 cm were contoured in the dome, right inferior, left medial, and central locations. SBRT and SBPT plans were generated to deliver 50 Gy in 5 fractions, max dose <135%. When organs-at-risk (OAR) constraints were exceeded, hypothetical plans (not clinically acceptable) were generated for comparison. Liver normal tissue complication probability (NTCP) models were applied to evaluate differences between treatment modalities. Results SBRT and SBPT were able to meet target goals and OAR constraints for lesions up to 7 cm and 9 cm diameter, respectively. SBPT plans resulted in a higher integral gross target dose for all lesions up to 7 cm (mean dose 57.8 ± 2.3 Gy to 64.1 ± 2.2 Gy, p < 0.01). Simultaneously, SBPT spared dose to the uninvolved liver in all locations (from 11.5 ± 5.3 Gy to 8.6 ± 4.4 Gy, p < 0.01), resulting in lower NTCP particularly for larger targets in the dome and central locations. SBPT also spared duodenal dose across all sizes and positions (from 7.3 ± 1.1 Gy to 1.1 ± 0.3 Gy, p < 0.05). Conclusion The main advantages of SBPT over SBRT is meeting plan goals and constrains for larger targets, particularly dome and central locations, and sparing dose to uninvolved liver. For such patients, SBPT may allow improvements in tumor control and treatment safety.
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Affiliation(s)
- W Tristram Arscott
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, United States
| | - Reid F Thompson
- Department of Radiation Medicine, Oregon Health & Science University, Portland VA Healthcare System, United States
| | - Lingshu Yin
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, United States
| | - Brendan Burgdorf
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, United States
| | - Maura Kirk
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, United States
| | - Edgar Ben-Josef
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, United States
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Hsieh M, Chang W, Yu H, Lu C, Chang C, Chow J, Chen S, Cheng Y, Wu S. Adjuvant radiotherapy and chemotherapy improve survival in patients with pancreatic adenocarcinoma receiving surgery: adjuvant chemotherapy alone is insufficient in the era of intensity modulation radiation therapy. Cancer Med 2018; 7:2328-2338. [PMID: 29665327 PMCID: PMC6010773 DOI: 10.1002/cam4.1479] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/24/2018] [Accepted: 03/02/2018] [Indexed: 12/13/2022] Open
Abstract
In the era of intensity modulation radiation therapy (IMRT), no prospective randomized trial has evaluated the efficacy of adjuvant therapies such as adjuvant concurrent chemoradiotherapy (CCRT), adjuvant sequential chemotherapy and radiotherapy (CT-RT), and adjuvant CT alone in resectable pancreatic adenocarcinoma (PA). Through propensity score matching, we designed a nationwide, population-based, head-to-head cohort study to determine the effects of dissimilar adjuvant treatments on resectable PA. We minimized the confounding of various adjuvant treatment outcomes among the following resectable PA groups of patients from the Taiwan Cancer Registry database: group 1, adjuvant CCRT; group 2, adjuvant sequential CT-RT; and group 3, adjuvant CT alone. All the studied techniques are IMRTs. The matching process yielded a final cohort of 588 patients (196, 196, and 196 patients in groups 1, 2, and 3, respectively). In both univariate and multivariate Cox regression analyses, adjusted hazard ratios (aHRs; 95% confidence interval [CI]) of death derived for the adjuvant CCRT and adjuvant sequential CT-RT cohorts compared with the adjuvant CT alone cohort were 0.398 (0.314-0.504) and 0.307 (0.235-0.402), respectively. A combination of adjuvant IMRT and CT for resectable PA treatment improves survival to a greater extent than does adjuvant CT alone.
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Affiliation(s)
- Mao‐Chih Hsieh
- Department of General SurgeryWan Fang HospitalTaipei Medical UniversityTaipeiTaiwan
| | - Wei‐Wen Chang
- Department of General SurgeryWan Fang HospitalTaipei Medical UniversityTaipeiTaiwan
| | - Hsin‐Hsien Yu
- Department of General SurgeryWan Fang HospitalTaipei Medical UniversityTaipeiTaiwan
| | - Chang‐Yun Lu
- Department of General SurgeryWan Fang HospitalTaipei Medical UniversityTaipeiTaiwan
| | - Chia‐Lun Chang
- Department of Hemato‐OncologyWan Fang HospitalTaipei Medical UniversityTaipeiTaiwan
| | - Jyh‐Ming Chow
- Department of Hemato‐OncologyWan Fang HospitalTaipei Medical UniversityTaipeiTaiwan
| | - Shee‐Uan Chen
- Department of Obstetrics and GynecologyNational Taiwan University HospitalTaipeiTaiwan
| | - Yunfeng Cheng
- Department of HematologyZhongshan Hospital Fudan UniversityShanghaiChina
- Department of HematologyZhongshan Hospital Qingpu BranchFudan UniversiyShanghaiChina
- Institute of Clinical ScienceZhongshan HospitalFudan UniversityShanghaiChina
- Shanghai Institute of Clinical BioinformaticsFudan University Center for Clinical BioinformaticsShanghaiChina
| | - Szu‐Yuan Wu
- Department of Radiation OncologyWan Fang HospitalTaipei Medical UniversityTaipeiTaiwan
- Department of Internal MedicineSchool of MedicineCollege of MedicineTaipei Medical UniversityTaipeiTaiwan
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Abstract
Pancreatic cancer is an aggressive malignancy with a poor long-term survival and only mild improvement in outcomes over the past 30 years. Local failure remains a problem and radiation can help improve control. The role of radiation therapy in has been controversial and is still evolving. This article reviews the trials of pancreatic cancer and radiation in adjuvant, neoadjuvant, and unresectable lesions. The article reviews the impact and outcomes of evolving radiation technology.
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Sousa N, Sousa O, Santos LL, Henrique R, Teixeira MR, Dinis-Ribeiro M, Teixeira-Pinto A. Lapatinib-capecitabine versus capecitabine alone as radiosensitizers in RAS wild-type resectable rectal cancer, an adaptive randomized phase II trial (LaRRC trial): study protocol for a randomized controlled trial. Trials 2016; 17:459. [PMID: 27655166 PMCID: PMC5031350 DOI: 10.1186/s13063-016-1583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 08/23/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Preoperative radiochemotherapy followed by surgical removal of the rectum with total mesorectum excision is the preferred treatment option for stages II and III rectal cancer. However, development of metastatic disease is the main cause of death for these patients with 5-year disease-free survival rates of 56 %. Anti-epidermal growth factor receptor (EGFR) targeted therapy is effective in metastatic rectal cancer, and human epidermal growth factor receptor 2 (HER-2) signaling may mediate resistance to EGFR inhibitors. Moreover, preclinical data support a synergistic effect of EGFR inhibition with radiation therapy. METHODS/DESIGN This Bayesian phase II trial with adaptive randomization was designed to assess the efficacy of adding lapatinib, a dual inhibitor of EGFR and HER-2, to standard radiochemotherapy with capecitabine in stages II and III rectal cancer. DISCUSSION The results of this trial will provide evidence of the feasibility and efficacy of the combination of lapatinib-capecitabine as radiosensitizers and explore potential predictive biomarkers for response to this novel neoadjuvant approach to resectable rectal cancer. TRIAL REGISTRATION EudraCT 2013-001203-36 . Registered on 13 December 2013.
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Affiliation(s)
- Nuno Sousa
- Medical Oncology Department, IPO Porto FG, EPE, Rua António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Olga Sousa
- Radioncology Department, IPO Porto FG, EPE, Rua António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Lúcio Lara Santos
- Surgical Oncology Department, IPO Porto FG, EPE, Rua António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Rui Henrique
- Department of Pathology, IPO Porto FG, EPE, Rua António Bernardino de Almeida, 4200-072 Porto, Portugal
- Department of Pathology and Molecular Immunology, Abel Salazar Institute of Biomedical Sciences – University of Porto, Rua de Jorge Viterbo Ferreira, no. 228, 4050-313 Porto, Portugal
| | - Manuel R. Teixeira
- Genetics Department, IPO Porto FG, EPE, Rua António Bernardino de Almeida, 4200-072 Porto, Portugal
- Biomedical Sciences Institute Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, IPO Porto FG, EPE, Rua António Bernardino de Almeida, 4200-072 Porto, Portugal
- CINTESIS - Center for Health Technology and Services Research, Centro de Investigação Médica, Faculdade de Medicina da Universidade do Porto, Rua Dr. Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Armando Teixeira-Pinto
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, NSW 2006 Australia
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Thompson RF, Mayekar SU, Zhai H, Both S, Apisarnthanarax S, Metz JM, Plastaras JP, Ben-Josef E. A dosimetric comparison of proton and photon therapy in unresectable cancers of the head of pancreas. Med Phys 2015; 41:081711. [PMID: 25086521 DOI: 10.1118/1.4887797] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Uncontrolled local growth is the cause of death in ∼ 30% of patients with unresectable pancreatic cancers. The addition of standard-dose radiotherapy to gemcitabine has been shown to confer a modest survival benefit in this population. Radiation dose escalation with three-dimensional planning is not feasible, but high-dose intensity-modulated radiation therapy (IMRT) has been shown to improve local control. Still, dose-escalation remains limited by gastrointestinal toxicity. In this study, the authors investigate the potential use of double scattering (DS) and pencil beam scanning (PBS) proton therapy in limiting dose to critical organs at risk. METHODS The authors compared DS, PBS, and IMRT plans in 13 patients with unresectable cancer of the pancreatic head, paying particular attention to duodenum, small intestine, stomach, liver, kidney, and cord constraints in addition to target volume coverage. All plans were calculated to 5500 cGy in 25 fractions with equivalent constraints and normalized to prescription dose. All statistics were by two-tailed paired t-test. RESULTS Both DS and PBS decreased stomach, duodenum, and small bowel dose in low-dose regions compared to IMRT (p < 0.01). However, protons yielded increased doses in the mid to high dose regions (e.g., 23.6-53.8 and 34.9-52.4 Gy for duodenum using DS and PBS, respectively; p < 0.05). Protons also increased generalized equivalent uniform dose to duodenum and stomach, however these differences were small (<5% and 10%, respectively; p < 0.01). Doses to other organs-at-risk were within institutional constraints and placed no obvious limitations on treatment planning. CONCLUSIONS Proton therapy does not appear to reduce OAR volumes receiving high dose. Protons are able to reduce the treated volume receiving low-intermediate doses, however the clinical significance of this remains to be determined in future investigations.
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Affiliation(s)
- Reid F Thompson
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Sonal U Mayekar
- Thomas Jefferson University, Philadelphia, Pennsylvania 19107
| | - Huifang Zhai
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Stefan Both
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | | | - James M Metz
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | | | - Edgar Ben-Josef
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
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13
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Bockbrader M, Kim E. Role of intensity-modulated radiation therapy in gastrointestinal cancer. Expert Rev Anticancer Ther 2014; 9:637-47. [DOI: 10.1586/era.09.16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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14
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Warren S, Partridge M, Fokas E, Eccles CL, Brunner TB. Comparing dose-volume histogram and radiobiological endpoints for ranking intensity-modulated arc therapy and 3D-radiotherapy treatment plans for locally-advanced pancreatic cancer. Acta Oncol 2013; 52:1573-8. [PMID: 23957620 DOI: 10.3109/0284186x.2013.813072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Samantha Warren
- The Gray Institute of Radiation Oncology and Biology, Department of Oncology, University of Oxford , Old Road Campus Research Building, Oxford , UK
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15
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Nakamura A, Shibuya K, Nakamura M, Matsuo Y, Shiinoki T, Nakata M, Mizowaki T, Hiraoka M. Interfractional dose variations in the stomach and the bowels during breathhold intensity-modulated radiotherapy for pancreatic cancer: Implications for a dose-escalation strategy. Med Phys 2013; 40:021701. [PMID: 23387724 DOI: 10.1118/1.4773033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE This study aims to evaluate the interfractional dose variations in the organs-at-risk (OARs) during pancreatic breathhold intensity-modulated radiotherapy (IMRT) and to assess the impacts of "planning organs-at-risk volume" (POV) structures generated by isotropically expanding the dose-limiting OARs, based on the comparison of the interfractional doses to the OARs between IMRT plans and conventional three-dimensional-conformal radiotherapy (3D-CRT) plans. METHODS Thirty repeat CT scans were acquired from ten consecutive patients who were receiving chemoradiotherapy for pancreatic cancer. Six IMRT plans for each patient with two levels of prescription (45 and 51 Gy in 15 fractions) and 3 POV margin sizes (5, 7, and 10 mm) were generated based on the initial CT scan under predetermined constraints. Two 3D-CRT plans (39 and 42 Gy in 15 fractions) were simultaneously generated. The dose distribution of all of the treatment plans was recalculated with the repeat CT scans. The interfractional dose variations in the three OARs (stomach, duodenum, and small intestine) were evaluated, and the absolute volumes ≥39 Gy (V39Gy) of the OARs in the IMRT plans were compared to those in the 3D-CRT plans. Regression analyses were performed to assess the relative impact of the factors of interest on the interfractional dose variations of the OARs. RESULTS Substantial dose excesses to the three OARs were observed at all of the prescription dose levels and the POV margin sizes on the repeat CT scans. The safety threshold based on the mean stomach V39Gy on the recalculated 39 Gy-3D-CRT plans was 1.9 ml. Statistically significant and marginally insignificant mean V39Gy values above the safety thresholds were observed in the stomach in the 51 Gy-IMRT plans (2.6 and 2.1 ml with the 5- and 7-mm PRV margins, respectively (P = 0.015 and 0.085)). Only in the case of the 10-mm POV margin did the metric fall below the safety threshold to 1.5 ml (P = 0.634). The duodenum and the small intestine did not violate the safety thresholds (1.4 and 3.8 ml, respectively). From the multiple regression analyses, only the margin size (P < 0.001) and the POV V39Gy (P < 0.001) were significantly associated with the distribution of recalculated V39Gy for the stomach. Multiple factors, including the margin size (P = 0.020) and the POV V39Gy (P < 0.001) were associated with the recalculated V39Gy for the duodenum. However, none of the POV parameters for the small intestine were associated with the recalculated V39Gy. CONCLUSIONS Considerable interfractional dose variation was observed in three critical OARs. At the escalated prescription dose of breathhold IMRT, the dose variations could exceed the dose variations using 3D-CRT at the safe prescription dose level, indicating that a dose-escalation strategy based solely on the initial advantageous dose distribution in a breathhold IMRT can be problematic. Given the current limitations for predicting or coping with variation throughout the treatment course, the use of POV should be considered for safely delivering escalated doses to patients with pancreatic cancer.
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Affiliation(s)
- Akira Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University, Kyoto, Japan
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16
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Wolfgang CL, Herman JM, Laheru DA, Klein AP, Erdek MA, Fishman EK, Hruban RH. Recent progress in pancreatic cancer. CA Cancer J Clin 2013; 63:318-48. [PMID: 23856911 PMCID: PMC3769458 DOI: 10.3322/caac.21190] [Citation(s) in RCA: 644] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 03/22/2013] [Accepted: 03/22/2013] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is currently one of the deadliest of the solid malignancies. However, surgery to resect neoplasms of the pancreas is safer and less invasive than ever, novel drug combinations have been shown to improve survival, advances in radiation therapy have resulted in less toxicity, and enormous strides have been made in the understanding of the fundamental genetics of pancreatic cancer. These advances provide hope but they also increase the complexity of caring for patients. It is clear that multidisciplinary care that provides comprehensive and coordinated evaluation and treatment is the most effective way to manage patients with pancreatic cancer.
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Affiliation(s)
- Christopher L. Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Joseph M. Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Daniel A. Laheru
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Alison P. Klein
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Epidemiology, the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael A. Erdek
- Department of Anesthesiology and Critical Care Medicine, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Elliot K. Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Ralph H. Hruban
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
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Wolfgang CL, Herman JM, Laheru DA, Klein AP, Erdek MA, Fishman EK, Hruban RH. Recent progress in pancreatic cancer. CA Cancer J Clin 2013. [PMID: 23856911 DOI: 10.1002/caac.21190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pancreatic cancer is currently one of the deadliest of the solid malignancies. However, surgery to resect neoplasms of the pancreas is safer and less invasive than ever, novel drug combinations have been shown to improve survival, advances in radiation therapy have resulted in less toxicity, and enormous strides have been made in the understanding of the fundamental genetics of pancreatic cancer. These advances provide hope but they also increase the complexity of caring for patients. It is clear that multidisciplinary care that provides comprehensive and coordinated evaluation and treatment is the most effective way to manage patients with pancreatic cancer.
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Affiliation(s)
- Christopher L Wolfgang
- Associate Professor, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Associate Professor, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD; Associate Professor, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD
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18
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Shukla P, Engineer R, Chopra S, Shrivastava SK. Endobiliary stent: marker for patient alignment in image-guided radiotherapy in pancreatic and periampullary cancers. J Gastrointest Cancer 2013; 44:393-7. [PMID: 23733213 DOI: 10.1007/s12029-013-9508-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of this study was to analyse the possibility of using stent in pretreatment megavoltage computed tomography (MVCT) images with respect to that on planning kilovoltage computed tomography as tumour surrogate during matching for daily registration in cases of pancreatic and periampullary cancer treated on a TomoTherapy Hi-Art system. METHODS Planning CT and pretreatment MVCT of the first and then after every three fractions were transferred to a FocalSim workstation for ten patients. Planning CT of each patient was independently fused with each of the seven MVCT images of that patient. The stent was contoured on all of the eight images for each patient. The difference between the three co-ordinates of centre of mass (CM) of the stent on the planning CT and seven MVCT images was found. The difference between CM of the liver and stents on the planning CT as well as on the MVCT for all seven fractions was also calculated. The mean of these differences across all patients was calculated and analysed. RESULTS The mean difference in planning and MVCT CMs for stents in the X, Y and Z directions was 0.13 cm (±0.4), 0.16 cm (±2.2) and 0.35 cm (±0.7), respectively. Average difference between CM of the liver and stent on the planning CT in the X, Y and Z directions was found to be 1.832 cm (±1.64), 5.34 cm (±1.33) and 0.54 cm (±0.26), respectively. Average difference between CM of the liver and CM of stent on the MVCT for that day in the X, Y and Z directions was found to be 1.93 cm (±1.5), 4.6 cm (±1.03) and 0.654 cm (±0.35), respectively. CONCLUSIONS Endobiliary stents are stable tumour localisation surrogates and can be used to correct for interfraction target motion.
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Affiliation(s)
- Pragya Shukla
- Departments of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Parel, Mumbai, 400012, India
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19
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A treatment planning comparison of four target volume contouring guidelines for locally advanced pancreatic cancer radiotherapy. Radiother Oncol 2013; 107:200-6. [DOI: 10.1016/j.radonc.2013.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 03/28/2013] [Accepted: 04/05/2013] [Indexed: 02/08/2023]
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20
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Fokas E, Eccles C, Patel N, Chu KY, Warren S, Gillies McKenna W, Brunner TB. Comparison of four target volume definitions for pancreatic cancer. Guidelines for treatment of the lymphatics and the primary tumor. Strahlenther Onkol 2013; 189:407-16. [PMID: 23553047 DOI: 10.1007/s00066-013-0332-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/13/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE Target volume definitions for radiotherapy in pancreatic ductal adenocarcinoma (PDAC) vary substantially. Some groups aim to treat the primary tumor only, whereas others include elective lymph nodes (eLNs). eLNs close to the primary tumor are often included unintentionally within the treatment volume, depending on the respective treatment philosophies. We aimed to measure the percentages of anatomical coverage of eLNs by comparing four different contouring guidelines. PATIENTS AND METHODS Planning target volumes (PTVs) were contoured using planning computed tomography (CT) scans of 11 patients with PDAC based on the Oxford, RTOG (Radiation Therapy Oncology Group), Michigan, and SCALOP (Selective Chemoradiation in Advanced Localised Pancreatic Cancer trial) guidelines. Clinical target volumes (CTVs) included the peripancreatic, para-aortic, paracaval, celiac trunk, superior mesenteric, and portal vein lymph node areas. Volumetric comparisons of the coverage of all eLN regions were conducted to illustrate the differences between the four contouring strategies. RESULTS The PTV sizes of the RTOG and Oxford guidelines were comparable. The SCALOP and Michigan PTV sizes were similar to each other and significantly smaller than the RTOG and Oxford PTVs. A large variability of eLN coverage was found for the various subregions according to the respective contouring strategies. CONCLUSION This is the first study to directly compare the percentage of anatomical coverage of eLNs according to four PTVs in the same patient cohort. Potential practical consequences are discussed in detail.
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Affiliation(s)
- E Fokas
- Gray Institute for Radiation Oncology and Biology, Department of Oncology, Oxford Cancer Centre, University of Oxford
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21
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Gurka MK, Collins SP, Slack R, Tse G, Charabaty A, Ley L, Berzcel L, Lei S, Suy S, Haddad N, Jha R, Johnson CD, Jackson P, Marshall JL, Pishvaian MJ. Stereotactic body radiation therapy with concurrent full-dose gemcitabine for locally advanced pancreatic cancer: a pilot trial demonstrating safety. Radiat Oncol 2013; 8:44. [PMID: 23452509 PMCID: PMC3607991 DOI: 10.1186/1748-717x-8-44] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 02/25/2013] [Indexed: 12/12/2022] Open
Abstract
Background Concurrent chemoradiation is a standard option for locally advanced pancreatic cancer (LAPC). Concurrent conventional radiation with full-dose gemcitabine has significant toxicity. Stereotactic body radiation therapy (SBRT) may provide the opportunity to administer radiation in a shorter time frame with similar efficacy and reduced toxicity. This Pilot study assessed the safety of concurrent full-dose gemcitabine with SBRT for LAPC. Methods Patients received gemcitabine, 1000 mg/m2 for 6 cycles. During week 4 of cycle 1, patients received SBRT (25 Gy delivered in five consecutive daily fractions of 5 Gy prescribed to the 75-83% isodose line). Acute and late toxicities were assessed using NIH CTCAE v3. Tumor response was assessed by RECIST. Patients underwent an esophagogastroduodenoscopy at baseline, 2, and 6 months to assess the duodenal mucosa. Quality of life (QoL) data was collected before and after treatment using the QLQ-C30 and QLQ-PAN26 questionnaires. Results Between September 2009 and February 2011, 11 patients enrolled with one withdrawal during radiation therapy. Patients had grade 1 to 2 gastrointestinal toxicity from the start of SBRT to 2 weeks after treatment. There were no grade 3 or greater radiation-related toxicities or delays for cycle 2 of gemcitabine. On endoscopy, there were no grade 2 or higher mucosal toxicities. Two patients had a partial response. The median progression free and overall survival were 6.8 and 12.2 months, respectively. Global QoL did not change between baseline and immediately after radiation treatment. Conclusions SBRT with concurrent full dose gemcitabine is safe when administered to patients with LAPC. There is no delay in administration of radiation or chemotherapy, and radiation is completed with minimal toxicity.
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Affiliation(s)
- Marie K Gurka
- Department of Radiation Oncology, Georgetown University Hospital, Washington, DC 20007, USA
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Ben-Josef E, Schipper M, Francis IR, Hadley S, Ten-Haken R, Lawrence T, Normolle D, Simeone DM, Sonnenday C, Abrams R, Leslie W, Khan G, Zalupski MM. A phase I/II trial of intensity modulated radiation (IMRT) dose escalation with concurrent fixed-dose rate gemcitabine (FDR-G) in patients with unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys 2012; 84:1166-71. [PMID: 22543215 DOI: 10.1016/j.ijrobp.2012.02.051] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/20/2012] [Accepted: 02/21/2012] [Indexed: 01/09/2023]
Abstract
PURPOSE Local failure in unresectable pancreatic cancer may contribute to death. We hypothesized that intensification of local therapy would improve local control and survival. The objectives were to determine the maximum tolerated radiation dose delivered by intensity modulated radiation with fixed-dose rate gemcitabine (FDR-G), freedom from local progression (FFLP), and overall survival (OS). METHODS AND MATERIALS Eligibility included pathologic confirmation of adenocarcinoma, radiographically unresectable, performance status of 0-2, absolute neutrophil count of ≥ 1,500/mm(3), platelets ≥ 100,000/mm(3), creatinine <2 mg/dL, bilirubin <3 mg/dL, and alanine aminotransferase/aspartate aminotransferase ≤ 2.5 × upper limit of normal. FDR-G (1000 mg/m(2)/100 min intravenously) was given on days -22 and -15, 1, 8, 22, and 29. Intensity modulated radiation started on day 1. Dose levels were escalated from 50-60 Gy in 25 fractions. Dose-limiting toxicity was defined as gastrointestinal toxicity grade (G) ≥ 3, neutropenic fever, or deterioration in performance status to ≥ 3 between day 1 and 126. Dose level was assigned using TITE-CRM (Time-to-Event Continual Reassessment Method) with the target dose-limiting toxicity (DLT) rate set to 0.25. RESULTS Fifty patients were accrued. DLTs were observed in 11 patients: G3/4 anorexia, nausea, vomiting, and/or dehydration (7); duodenal bleed (3); duodenal perforation (1). The recommended dose is 55 Gy, producing a probability of DLT of 0.24. The 2-year FFLP is 59% (95% confidence interval [CI]: 32-79). Median and 2-year overall survival are 14.8 months (95% CI: 12.6-22.2) and 30% (95% CI 17-45). Twelve patients underwent resection (10 R0, 2 R1) and survived a median of 32 months. CONCLUSIONS High-dose radiation therapy with concurrent FDR-G can be delivered safely. The encouraging efficacy data suggest that outcome may be improved in unresectable patients through intensification of local therapy.
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Affiliation(s)
- Edgar Ben-Josef
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA.
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Goodman KA, Regine WF, Dawson LA, Ben-Josef E, Haustermans K, Bosch WR, Turian J, Abrams RA. Radiation Therapy Oncology Group consensus panel guidelines for the delineation of the clinical target volume in the postoperative treatment of pancreatic head cancer. Int J Radiat Oncol Biol Phys 2012; 83:901-8. [PMID: 22483737 DOI: 10.1016/j.ijrobp.2012.01.022] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 01/04/2012] [Accepted: 01/05/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To develop contouring guidelines to be used in the Radiation Therapy Oncology Group protocol 0848, a Phase III randomized trial evaluating the benefit of adjuvant chemoradiation in patients with resected head of pancreas cancer. METHODS AND MATERIALS A consensus committee of six radiation oncologists with expertise in gastrointestinal radiotherapy developed stepwise contouring guidelines and an atlas for the delineation of the clinical target volume (CTV) in the postoperative treatment of pancreas cancer, based on identifiable regions of interest and margin expansions. Areas at risk for subclinical disease to be included in the CTV were defined, including nodal regions, anastomoses, and the preoperative primary tumor location. Regions of interest that could be reproducibly contoured on postoperative imaging after a pancreaticoduodenectomy were identified. Standardized expansion margins to encompass areas at risk were developed after multiple iterations to determine the optimal margin expansions. RESULTS New contouring recommendations based on CT anatomy were established. Written guidelines for the delineation of the postoperative CTV and normal tissues, as well as a Web-based atlas, were developed. CONCLUSIONS The postoperative abdomen has been a difficult area for effective radiotherapy. These new guidelines will help physicians create fields that better encompass areas at risk and minimize dose to normal tissues.
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Affiliation(s)
- Karyn A Goodman
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Sangalli G, Passoni P, Cattaneo GM, Broggi S, Bettinardi V, Reni M, Slim N, Muzio ND, Calandrino R. Planning design of locally advanced pancreatic carcinoma using 4DCT and IMRT/IGRT technologies. Acta Oncol 2011; 50:72-80. [PMID: 20482224 DOI: 10.3109/0284186x.2010.484425] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE to study the impact of the 4DCT imaging technique on radiotherapy planning for pancreatic carcinoma. To evaluate the possibility of IMRT/IGRT to increase the dose to PTV subvolume. MATERIAL AND METHODS contrast-enhanced 4DCT scans of 15 patients (PTs) with unresectable pancreatic cancer were acquired. A 4DCT based PTV (4D-PTV) was created by the convolution of contours and then expanded for geometric uncertainties; a standard PTV (STD-PTV) was derived from a single CTV plus conventional margins. Two 3D conformal treatment (3DCRT) plans and one Helical Tomotherapy (HT) plan were generated with a prescription of 60 Gy. Regarding the 3DCRT plans, the 4D-PTV was considered as the target volume for one, and the STD-PTV for the other; the HT plans were performed only for 4D-PTV. Twelve of 15 PTs were admitted to a Phase I hypofractionated study (15 fractions). The prescribed dose was 44.25 Gy to the 4D-PTV and the PTV subvolume around vascular involvement was boosted from 50 to 55 Gy; before treatment, daily patient position was corrected using MVCT. RESULTS 4D-PTVs were smaller than STD-PTVs with a volume reduction equal to 37%. 3DCRT plans on 4D-PTV showed a significant sparing of most OARs, the use of IMRT allowed a further significant dose reduction. In the Phase I study the PTV subvolume received up to 55 Gy with modest increase in dose to OARs. CONCLUSIONS the 4DCT procedure decreases the overlap between PTV and OARs. HT technique, compared with 3DCRT, allows efficient dose sparing in particular for the duodenum. The IMRT/IGRT approach allows a safe dose escalation to PTV subvolume.
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Affiliation(s)
- Giulia Sangalli
- Medical Physics Department, San Raffaele Scientific Institute, Milan, Italy
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Sun W, Leong CN, Zhang Z, Lu JJ. Proposing the lymphatic target volume for elective radiation therapy for pancreatic cancer: a pooled analysis of clinical evidence. Radiat Oncol 2010; 5:28. [PMID: 20398316 PMCID: PMC2859771 DOI: 10.1186/1748-717x-5-28] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/15/2010] [Indexed: 02/08/2023] Open
Abstract
Background Radiation therapy is an important cancer treatment modality in both adjuvant and definitive setting, however, the use of radiation therapy for elective treatment of regional lymph nodes is controversial for pancreatic cancer. No consensus on proper selection and delineation of subclinical lymph nodal areas in adjuvant or definitive radiation therapy has been suggested either conclusively or proposed for further investigation. This analysis aims to study the pattern of lymph node metastasis through a pooled analysis of published results after radical tumor and lymph nodal resection with histological study in pancreatic cancer. Methods Literature search using electronic databases including MEDLINE, EMBASE, and CANCERLIT from January 1970 to June 2009 was performed, supplemented by review of references. Eighteen original researches and a total of 5954 pancreatic cancer patients underwent radical surgical resection were included in this analysis. The probability of metastasis in regional lymph nodal stations (using Japan Pancreas Society [JPS] Classification) was calculated and analyzed based on the location and other characteristics of the primary disease. Results Commonly involved nodal regions in patients with pancreatic head tumor include lymph nodes around the common hepatic artery (Group 8, 9.79%), posterior pancreaticoduodenal lymph nodes (Group 13, 32.31%), lymph nodes around the superior mesenteric artery (Group 14, 15.85%), paraaortic lymph nodes (Group 16, 10.92%), and anterior pancreaticoduodenal lymph nodes (Group 17, 19.78%); The probability of metastasis in other lymph nodal regions were <9%. Commonly involved nodal regions in patients with pancreatic body/tail tumor include lymph nodes around the common hepatic artery (Group 8, 15.07%), lymph nodes around the celiac trunk (Group 9, 9.59%), lymph nodes along the splenic artery (Group 11, 35.62%), lymph nodes around the superior mesenteric artery (Group 14, 9.59%), paraaortic lymph nodes (Group 16, 16.44%), and inferior body lymph nodes (Group 18, 24.66%). The probability of metastasis in other lymph nodal regions were <9%. Conclusions Pancreatic cancer has a high propensity of regional lymphatic metastases; however, clear patterns including the site and probability of metastasis can be identified and used as a guide of treatment in patients with resectable pancreatic cancer. Further clinical investigation is needed to study the efficacy of elective treatment to CTV defined based on these patterns using high-dose conformal or intensity-modulated radiation therapy.
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Affiliation(s)
- Wenjie Sun
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Stereotactic body radiation therapy boost in locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys 2009; 75:1456-61. [PMID: 19783379 DOI: 10.1016/j.ijrobp.2009.01.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 01/06/2009] [Accepted: 01/14/2009] [Indexed: 02/07/2023]
Abstract
PURPOSE To investigate the clinical application of a stereotactic body radiation therapy (SBRT) boost in locally advanced pancreatic cancer patients with a focus on local efficacy and toxicity. METHODS AND MATERIALS We retrospectively reviewed 30 patients with locally advanced and nonmetastatic pancreatic cancer who had been treated between 2004 and 2006. Follow-up duration ranged from 4 to 41 months (median, 14.5 months). A total dose of 40 Gy was delivered in 20 fractions using a conventional three-field technique, and then a single fraction of 14, 15, 16, or 17 Gy SBRT was administered as a boost without a break. Twenty-one patients received chemotherapy. Overall and local progression-free survival were calculated and prognostic factors were evaluated. RESULTS One-year overall survival and local progression-free survival rates were 60.0% and 70.2%, respectively. One patient (3%) developed Grade 4 toxicity. Carbohydrate antigen 19-9 response was found to be an independent prognostic factor for survival. CONCLUSIONS Our findings indicate that a SBRT boost provides a safe means of increasing radiation dose. Based on the results of this study, we recommend that a well controlled Phase II study be conducted on locally advanced pancreatic cancer.
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Bouchard M, Amos RA, Briere TM, Beddar S, Crane CH. Dose escalation with proton or photon radiation treatment for pancreatic cancer. Radiother Oncol 2009; 92:238-43. [PMID: 19454367 DOI: 10.1016/j.radonc.2009.04.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 04/16/2009] [Accepted: 04/18/2009] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose was to determine the optimal radiation therapy modality (three-dimensional conformal photon-radiation therapy [3DCRT], intensity-modulated photon-radiation therapy [IMRT], or passive-scattering proton therapy [PT]) for safe dose escalation (72Gy) in pancreatic tumors in different positions relative to organs at risk (OAR) anatomy. METHODS AND MATERIALS A 3-cm pancreatic tumor was virtually translated every 5mm over 5cm laterally. We generated two plans for each of the three techniques (3DCRT, IMRT, and PT), one that adhered to target coverage objectives and another to meet OAR sparing constraints with best coverage. We evaluated distances between gross tumor volumes and isodoses and compared dose-volume histograms. RESULTS IMRT was more conformal in higher gradient dose regions circumferentially, but tumor positions with anteriorly located small bowel benefited more from PT. 3DCRT plans resulted in inadequate target coverage. The V(15Gy) (mean+/-SD) were as follows for the IMRT and PT plans, respectively: stomach, 48%+/-4% vs 5%+/-3% (p<0.0001); and small bowel, 61%+/-8% vs 9%+/-4% (p<0.0001). CONCLUSIONS Our study showed that the optimal radiation therapy modality for safe dose escalation depends on pancreatic tumor position in relation to OAR anatomy.
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Affiliation(s)
- Myriam Bouchard
- Department of Radiation Physics, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Feng M, Balter JM, Normolle D, Adusumilli S, Cao Y, Chenevert TL, Ben-Josef E. Characterization of pancreatic tumor motion using cine MRI: surrogates for tumor position should be used with caution. Int J Radiat Oncol Biol Phys 2009; 74:884-91. [PMID: 19395190 DOI: 10.1016/j.ijrobp.2009.02.003] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 02/01/2009] [Accepted: 02/02/2009] [Indexed: 01/09/2023]
Abstract
PURPOSE Our current understanding of intrafraction pancreatic tumor motion due to respiration is limited. In this study, we characterized pancreatic tumor motion and evaluated the application of several radiotherapy motion management strategies. METHODS AND MATERIALS Seventeen patients with unresectable pancreatic cancer were enrolled in a prospective internal review board-approved study and imaged during shallow free-breathing using cine MRI on a 3T scanner. Tumor borders were agreed on by a radiation oncologist and an abdominal MRI radiologist. Tumor motion and correlation with the potential surrogates of the diaphragm and abdominal wall were assessed. These data were also used to evaluate planning target volume margin construction, respiratory gating, and four-dimensional treatment planning for pancreatic tumors. RESULTS Tumor borders moved much more than expected. To provide 99% geometric coverage, margins of 20 mm inferiorly, 10 mm anteriorly, 7 mm superiorly, and 4 mm posteriorly are required. Tumor position correlated poorly with diaphragm and abdominal wall position, with patient-level Pearson correlation coefficients of -0.18-0.43. Sensitivity and specificity of gating with these surrogates was also poor, at 53%-68%, with overall error of 35%-38%, suggesting that the tumor may be underdosed and normal tissues overdosed. CONCLUSIONS Motion of pancreatic tumor borders is highly variable between patients and larger than expected. There is substantial deformation with breathing, and tumor border position does not correlate well with abdominal wall or diaphragmatic position. Current motion management strategies may not account fully for tumor motion and should be used with caution.
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Affiliation(s)
- Mary Feng
- Department of Radiation Oncology, University of Michigan, USA.
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Multicriteria optimization in intensity-modulated radiation therapy treatment planning for locally advanced cancer of the pancreatic head. Int J Radiat Oncol Biol Phys 2008; 72:1208-14. [PMID: 18954714 DOI: 10.1016/j.ijrobp.2008.07.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 07/11/2008] [Accepted: 07/20/2008] [Indexed: 01/27/2023]
Abstract
PURPOSE Intensity-modulated radiation therapy (IMRT) affords the potential to decrease radiation therapy-associated toxicity by creating highly conformal dose distributions. However, the inverse planning process can create a suboptimal plan despite meeting all constraints. Multicriteria optimization (MCO) may reduce the time-consuming iteration loop necessary to develop a satisfactory plan while providing information regarding trade-offs between different treatment planning goals. In this exploratory study, we examine the feasibility and utility of MCO in physician plan selection in patients with locally advanced pancreatic cancer (LAPC). METHODS AND MATERIALS The first 10 consecutive patients with LAPC treated with IMRT were evaluated. A database of plans (Pareto surface) was created that met the inverse planning goals. The physician then navigated to an "optimal" plan from the point on the Pareto surface at which kidney dose was minimized. RESULTS Pareto surfaces were created for all 10 patients. A physician was able to select a plan from the Pareto surface within 10 minutes for all cases. Compared with the original (treated) IMRT plans, the plan selected from the Pareto surface had a lower stomach mean dose in 9 of 10 patients, although often at the expense of higher kidney dose than with the treated plan. CONCLUSION The MCO is feasible in patients with LAPC and allows the physician to choose a satisfactory plan quickly. Generally, when given the opportunity, the physician will choose a plan with a lower stomach dose. The MCO enables a physician to provide greater active clinical input into the IMRT planning process.
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Meyer JJ, Czito BG, Willett CG. Intensity-modulated radiation therapy for gastrointestinal tumors. Curr Oncol Rep 2008; 10:206-11. [DOI: 10.1007/s11912-008-0032-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Ben-Josef E, Lawrence TS. Chemoradiotherapy for unresectable pancreatic cancer. Int J Clin Oncol 2008; 13:121-6. [PMID: 18463955 DOI: 10.1007/s10147-007-0763-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Indexed: 12/12/2022]
Abstract
Treatment options for unresectable pancreatic cancer, including concurrent chemoradiotherapy, chemotherapy alone, and chemotherapy followed by chemoradiotherapy, are largely ineffective and result in a median survival of approximately 10-12 months. Although quality data on the benefit of radiotherapy in unresectable pancreatic cancer are lacking, it seems unlikely that the low-efficacy chemotherapy used for pancreatic cancer would control gross disease. Current regimens deliver low, ineffective doses of radiation and are associated with high rates of local failure. New technological advances, such as intensity-modulated radiotherapy, now allow the safe delivery of high-dose, highly conformal radiotherapy concurrently with full systemic doses of chemotherapy. We review new knowledge related to pattern of failure, target definition, and target motion and discuss the implications of these data on modern radiotherapy treatment planning and delivery. While it is clear that breakthroughs in treatment would come mostly from advances in systemic therapy, the evidence suggests that radiotherapy should not fall out of use, but rather be intensified.
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Affiliation(s)
- Edgar Ben-Josef
- Department of Radiation Oncology, University of Michigan Medical Center, UH-B2C490 1500 East Medical Center Drive, Ann Arbor, MI, 48109-0010, USA.
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Lin A, Ben-Josef E. Intensity-modulated radiation therapy for the treatment of anal cancer. Clin Colorectal Cancer 2008; 6:716-9. [PMID: 18039425 DOI: 10.3816/ccc.2007.n.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this study was to assess whether intensity-modulated radiation therapy (RT; IMRT) can reduce dose to normal tissues (organs at risk) while maintaining equivalent target coverage. PATIENTS AND METHODS A 9-field, non-coplanar, 1-cm beamlet IMRT plan was designed for 9 patients who were previously treated for anal cancer with conventional field arrangements. Clinical target volumes and organs at risk (OARs) were defined. Target coverage was assigned highest priority for optimization, followed sequentially by organ at risk. The genitalia and perineal skin were the highest priority OARs. Lexicographic ordering-based IMRT optimization was used to generate a conformal plan, which was compared with the conventional, previously delivered RT plan. RESULTS The IMRT and conventional RT plan achieved homogeneous dose coverage of all target volumes. Intensity-modulated RT produced highly conformal dose distributions compared with conventional techniques, with avoidance of critical normal structures. Statistically significant reductions in mean doses to the perineal skin and to the genitalia were seen with IMRT, with only a modest increase in mean dose to the bony pelvis. CONCLUSION Intensity-modulated RT, with lexicographic ordering, allows for substantial reduction of dose to OARs while maintaining adequate target coverage. These encouraging findings might translate into reductions of treatment-related toxicity, gains in local control, or improvements in quality of life.
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Affiliation(s)
- Alexander Lin
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109-0010.
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Meyer JJ, Willett CG, Czito BG. Is there a role for advanced radiation therapy technologies in the treatment of pancreatic adenocarcinoma? Future Oncol 2008; 4:241-55. [DOI: 10.2217/14796694.4.2.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pancreatic cancer remains a highly challenging problem in oncology. Oncologists continue to search for therapies that are more effective than those currently available to improve on the existing poor treatment results. Persistence of both systemic and local disease causes high rates of morbidity and mortality for patients. Radiation continues to play a role in the treatment of pancreatic cancer, in both the adjuvant and locally advanced settings. Efforts to improve on the results of radiotherapy have led to the use of new and improved technologies. This review discusses a variety of these technological improvements and their current and potential future roles in the clinic.
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Affiliation(s)
- Jeffrey John Meyer
- Duke University Medical Center, Department of Radiation Oncology, DUMC Box 3085, Durham, NC 27710, USA
| | | | - Brian Gary Czito
- Duke University Medical Center, Department of Radiation Oncology, DUMC Box 3085, Durham, NC 27710, USA
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